A nurse is performing a dietary assessment for a client. Which of the following questions should the nurse ask when assessing the client's dietary acculturation?
"What questions do you have about reading food labels?”
"Do you have special customs that you follow for meals?”
"Are there any foods that you are allergic to?"
"How do you feel about your current body weight”
The Correct Answer is B
Rationale:
A. "What questions do you have about reading food labels?": This question assesses nutrition literacy rather than dietary acculturation. It focuses on understanding nutritional information, not cultural food practices or adaptations.
B. "Do you have special customs that you follow for meals?": This question directly addresses dietary acculturation by exploring cultural or traditional food practices and meal patterns. It helps the nurse understand how the client’s cultural background influences their diet and eating behaviors.
C. "Are there any foods that you are allergic to?": This question assesses food safety and potential allergens, not cultural or acculturation aspects of the diet.
D. "How do you feel about your current body weight?": This question addresses body image and personal perception, which may influence dietary choices but does not provide information about cultural or acculturation influences on diet.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Crusting of exudate on the incisional line: A small amount of dried exudate forming a crust along the incision is a normal part of the healing process and typically does not indicate infection or complication. It protects the tissue underneath and usually resolves with routine hygiene, so it does not require immediate reporting.
B. Mild swelling under the sutures near the incisional line: Mild localized swelling is expected in the early postoperative period due to inflammation and tissue repair. This is a common finding and generally resolves as healing progresses, making it a normal assessment observation.
C. Partial separation of the upper part of the incisional line: Partial dehiscence is a serious complication that can lead to infection, evisceration, or delayed healing. This finding requires prompt notification of the provider for immediate intervention, which may include wound closure, protective dressing, or surgical management.
D. Pink-tinged coloration on the incisional line: Light pink coloration along the incision indicates normal healing and adequate perfusion of the tissue. It reflects healthy granulation tissue formation and is expected in the early stages postoperatively, so it does not require urgent reporting.
Correct Answer is A
Explanation
Rationale:
A. Check the client for indications of bleeding: The priority action following a heparin overdose is to assess the client for signs of active or internal bleeding, such as hematuria, melena, bruising, or hypotension. Immediate assessment guides urgent interventions to prevent life-threatening complications.
B. Monitor the client's aPTT levels: Monitoring aPTT is important to evaluate the anticoagulant effect and guide treatment, but it is secondary to assessing for actual bleeding. Assessment of clinical signs takes precedence over laboratory monitoring in urgent situations.
C. Complete an incident report: Documenting the medication error is necessary for legal and quality improvement purposes, but it is not the first action. Patient safety and immediate clinical assessment come before reporting.
D. Notify the risk manager: Informing the risk manager is part of the incident reporting process, but addressing the client’s immediate safety needs comes first. Notification can occur after urgent assessment and stabilization.
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